Physicians Report Barriers to Implementing Choosing Wisely

Bridget M. Kuehn

October 03, 2016

Primary care physicians find many of the Choosing Wisely recommendations are easy to follow, according to a recent national survey. However, they anticipate patient resistance and other barriers when it comes to implementing recommendations to avoid testing or treatment for symptomatic conditions.

With more than half of US physicians reporting that their patients receive more care than they need, the American Board of Internal Medicine launched the Choosing Wisely campaign in 2012 to help cut unnecessary care.

So far, more than 70 medical societies have developed more than 450 such recommendations that identify procedures, tests, or medications physicians should avoid, according to the American Board of Internal Medicine.

However, there has not been much information on how physicians feel about the recommendations and how easily they can be implemented, according to Brian J. Zikmund-Fisher, PhD, an associate professor of Health Behavior and Health Education at the University of Michigan, and colleagues.

"Even if providers agree with efforts to reduce overuse of services in principle, concerns about individual recommendations have the potential to impede efforts to reduce use of specific services," Dr Zikmund-Fisher and colleagues write in their article, published online September 6 in the Journal of General Internal Medicine.

To gauge primary care physicians' views on the campaign's recommendations, the authors surveyed 2000 US primary care physicians and 2500 primary care providers at the Department of Veterans Affairs about 12 Choosing Wisely recommendations. The recommendations addressed four diagnostic tests, four screening tests, and four medications that are likely to cause harm or incur unnecessary costs if overused.

Of those participants, 603 (34%) were US primary care physicians and 1173 (48%) were Veterans Affairs primary care physicians. The authors found similar responses across the two groups of physicians.

Many physicians were not familiar with the Choosing Wisely campaign, with 40% of the US primary care respondents and 63% of Veterans Affairs respondents indicating they were "not at all familiar" with it.

More than 80% of physicians reported that it would not be difficult to implement or for patients to accept four of the recommendations to avoid overscreening or overtesting for colon cancer or cardiac problems.

However, three recommendations were rated by more than 20% of physicians as both difficult to follow and difficult for patients to accept, including imaging for suspected pulmonary embolism, avoiding the use of medications to achieve hemoglobin A1c levels lower than 7.5% in adults aged 65 years and older, and avoiding dual-energy X-ray absorptiometry screening in younger patients with no risk factors.

In addition, five recommendations related to testing or treating symptomatic patients were rated as likely to be difficult for patients to accept by 35.7% to 87.1% of responding physicians. Of these five, the recommendations most consistently identified as difficult to implement were limiting use of antibiotics for sinusitis, avoiding imaging for low back pain in the first 6 weeks, and not prescribing benzodiazepines and other sedative-hypnotics as a first choice for treating insomnia, agitation, or delirium in older adults.

"While [primary care physicians] found many [Choosing Wisely] recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept," the authors conclude.

The surveyed physicians reported that frequent barriers to implementing the Choosing Wisely recommendations were concern about malpractice lawsuits, patient requests for interventions, tests recommended by specialists, and inadequate time to engage patients in shared decision-making.

The low response rate was a limitation of the study, according to the authors. "Our less than optimal response rates reflect how difficult it has become to conduct nationally representative surveys of clinicians, especially without large financial incentives," the authors write.

The authors note that they were particularly concerned that physicians were anticipating high resistance from patients for certain recommendations. They add that brief interventions could help shift patients' attitudes.

"[O]ur findings are concerning, because they suggest that providers might be anticipating patient barriers to acceptance of recommendations to reduce service utilization that either do not exist or could be easily overcome," the authors write. "Unfortunately, such anticipatory concern could become a self-fulfilling prophecy."

The authors suggest that targeted interventions are needed to help overcome physician and patient reluctance to adopt some of Choosing Wisely's recommendations.

"Anticipation of patient concerns should not be allowed to create undue hesitation in efforts to implement such initiatives," they write. "However, it is likely that interventions will need to extend beyond [primary care provider]-directed education, feedback, and incentives, in order to impact change for recommendations that [primary care providers] fear patients will reject."

The study was funded in part by the Center for Healthcare Research and Transformation, a nonprofit partnership between the University of Michigan and Blue Cross Blue Shield of Michigan; the Veteran's Health Administration; and the Department of Veterans Affairs. The authors have disclosed no relevant financial relationships.

J Gen Intern Med. Published online September 6, 2016. Full text

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